How a Pacemaker Made Cancer Doc a Better Clinician

The wit and wisdom of Larry Norton

During his term as president of the American Society of Clinical Oncology (ASCO), Larry Norton, MD, kept secret an uncomfortable medical condition, an experience that would ultimately help him grow as a clinician.

"I had a bad viral syndrome, and when I was traveling in Malta I had a pure fainting episode," he said during an exclusive interview with MedPage Today.

Norton -- deputy physician-in-chief for breast cancer programs and medical director of the Evelyn H. Lauder Breast Center at Memorial Sloan Kettering Cancer Center, and co-founder and scientific director of the Breast Cancer Research Foundation -- explained that his physicians in Malta were concerned that he might faint again on his way back to New York, so following a cardiac catheterization they inserted a pacemaker.

Stateside, physicians told him it wouldn't be a big deal to just leave the pacemaker in place if it wasn't bothering him.

"Well it turned out to be a big deal," Norton said. "I had developed superior vena cava obstruction -- 1 case in 10,000."

In Malta he was told that taking out the pacemaker would be trivial, but it had been inserted in such a way that its removal required special expertise.

Norton went from one medical expert to another, finding that each had their own way of proceeding with his case. "That's not what I wanted to hear," he said. "I wanted to know, what's the best way to have it removed -- not just, 'I propose to do it this way.'"

Norton said he lived with the condition during his ASCO presidency, from 2001 to 2002, and that photos of him during that time show facial edema. He didn't "want to screw with" the pacemaker until the end of his term.

"I did my own literature search and eventually had it removed without any complications," Norton explained. "I've been fine ever since -- and nothing was ever wrong with my heart."

That experience helped reinforce how he deals with patients in his breast cancer practice, and what he teaches to other medical professionals. "You never know how God works. You never know when a bad thing turns into a good thing, because of where it can lead," he said. "For other people or for yourself."

Norton now tells his breast cancer patients what he recommends and why, telling them that other oncologists may have different opinions and also explaining what they might be and why. He explains to his patients how these other approaches might be valid, and why it is important that they think very carefully about what they want done. When he thinks a different approach may be more beneficial to a patient, he makes the appropriate referral.

"If people really understand the situation, the nuances, the reasons why the decision is right for them, then with enough discussion it will become the right decision."

Intrigued by the medical decision-making process, Norton said that indecision or confusion is usually caused by a lack of information.

"Decisions make themselves with sufficient information," he said, and with more studying the right answer they become obvious rather than guesswork. He cautioned not to deliberate indefinitely, however, as "people who take a long time to make a decision tend to be unhappy with any decision they make."

Confidence is also important, Norton said. When the right decision is obvious, "stick with it and don't waffle."

Norton has reservations about the current role of artificial intelligence (AI) in medicine, noting that the "intelligence" is not always intelligent in practice. "AI can be stupid," he said, since a toddler can identify a cat while a computer might require millions of data points, trial and error, and still mistakenly identify that very same cat.

"AI has an important role, but it needs to be put in context," he said. "Big data is important and can generate hypotheses, but still needs prospective randomized trials for confirmation."

He said that someday -- with sufficient data -- AI may be more useful, but at the moment it is a very inefficient process.

"The tool should be utilized for what it's designed for, and we should not let the tool determine what questions are being asked," he said. "AI's value is to generate hypotheses, and there are questions that humans can answer but computers will never answer."

Physics, Music, and Math

Norton is reflective about the issues he discusses, and often explains medicine in philosophical terms, incorporating physics, math and music.

Intense and highly spiritual, Norton said he always feels the presence of a greater force, which has been deeply motivating and an important part of his life. There are hard and fast rules in the universe, he said, such as the rules of physics, which might be considered arbitrary but are still there. Similarly, he added, there are ethical rules that are immutable and codified in religion.

Growing up on Long Island, the son of a New York Post editor, he assumed his career would be either in music or as an academic mathematician.

When he travels, Norton often takes musical scores and reads them on airplanes, hearing the music in his head. Extolling the beauty, grandness and art of math, he said that on paper math exists in the same way to the minds of mathematicians.

Mathematics has played a significant part in his work. Norton co-developed the Norton–Simon Hypothesis -- with Richard Simon, ScD, of the National Cancer Institute (NCI) -- which states that the rate a cancer will shrink, in response to treatment, is directly proportional to the tumor's growth rate.

Last spring, the Breast Cancer Research Foundation announced it was launching the Mathematical Oncology Initiative at Memorial Sloan Kettering. Led by Norton with physicist Joseph Deasy, PhD, and mathematician Allen Tannenbaum, PhD, the initiative will bring together mathematicians, computer scientists and physicists to work with biologists and oncologists to increase understanding of cancer and metastasis in an effort to improve treatments and outcomes.

He is a fierce proponent of publicly funded research, as it removes the possible vested interests of industry.

Norton said that he's also currently involved in establishing a bio-oncology center at Soroka Medical Center in Beersheba, Israel. In affiliation with Ben-Gurion University of the Negev, the center will focus on the mathematics of cancer. "Israel is a wonderful place for molecular epidemiological research and to test hypotheses, since the entire population has medical insurance and electronic health records."

Music and math were Norton's two loves when he was an undergraduate at the University of Rochester, where he also was enrolled in its Eastman School of Music.

But a friend at Rochester who also went on to become a distinguished oncologist, Ronald Blum, MD, informed him about a summer program at Roswell Park Cancer Institute in Buffalo, N.Y.

"Ron opened the door for me, and I got hooked," Norton said. He spent a few summers at Roswell, becoming interested in oncology when he witnessed the curative effect of methotrexate, which he said was the most magical thing he had seen.

He received his MD from Columbia University's College of Physicians and Surgeons, trained in internal medicine at the Albert Einstein College of Medicine, and served as a clinical associate and investigator at the NCI before joining the faculty of the Mount Sinai Medical Center in New York City. In 1988 he left Mount Sinai for a position at Memorial Sloan Kettering.

Norton was formerly chair of the Breast Committee of the NCI's Cancer and Leukemia Group B and served on NCI's National Cancer Advisory Board from 1998 to 2004. He has few regrets, but does often question whether he could have made more scientific contributions had he not continued to practice clinical medicine along with his research.

Norton's career hasn't gotten in the way of his love of music, which always remained a central part of his life -- jazz especially. He plays multiple instruments, ranging from brass, reed, percussion, and strings. He plays mostly with friends, and can often be seen wearing earplugs to preserve his hearing.

"I've also done a number of benefits," he said, "including two with Elton John, playing electronic violin and then chromatic harmonica, as well as the vibraphone with Paul Shaffer, whom I'll be appearing with again playing bass next month."

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